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12-year-old boy in whom a benign gastric ulcer perforated into the free abdominal cavity is reported. He has underwent emergency operation with a preoperative diagnosis of acute peritonitis due to perforation of peptic ulcer. Gastric ulcer is a rare disease of childhood. The illness was discussed in view of the literature.
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This article reviews recently published reports on ulcers and gastritis. Helicobacter pylori is known to be an important pathogen involved in gastroduodenal inflammation and peptic ulcers. Conventional endoscopy is of limited usefulness in the evaluation of gastritis, but magnifying endoscopy is evidently helpful in the diagnosis of chronic atrophic gastritis, intestinal metaplasia, and H. pylori infection. A significant reduction in the incidence of refractory ulcers and the prevalence of H. pylori infection in patients with peptic ulcer disease followed the introduction of H. pylori eradication treatment. Chronic H. pylori infection is associated with gastric cancer, and the effect of H. pylori eradication on the prevention of gastric cancer is an important issue that is still a matter of controversy. Endoscopic hemostasis and intravenous proton-pump inhibitor (PPI) infusion represent a widely accepted approach to the treatment of peptic ulcer bleeding. In clinical practice, it is important to prevent recurrent bleeding and to treat patients who do not respond to endoscopic therapy or PPI treatment. Laparoscopic repair for peptic ulcer perforations, with postoperative eradication treatment, has gradually met with acceptance in patients with H. pylori infection. H. pylori infection and its treatment continue to be interesting problems in this field.
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Most significant research relating to gastric surgery in the past year has centered on surgery for gastroesophageal reflux disease (GERD). Antireflux surgery has become more popular with advanced laparoscopic technology. Two previously accepted surgical principles have been challenged by current studies: the importance of division of the short gastrics and the dictum that partial fundoplication is preferred for patients at risk for dysphagia. Additionally, risk factors for postoperative dysphagia have been identified, allowing for better patient selection and education. Further study on the cause of GERD has shown a positive correlation between pathologic gastroesophageal reflux and those with hiatal hernia or disordered esophageal peristalsis, although cause or effect has not yet been established. Literature relating to bariatric surgery has confirmed the safety and efficacy of the laparoscopic Roux-en-Y gastric bypass, and several papers address the appropriateness of prophylactic cholecystectomy in these patients. The role of laparoscopic surgery for treatment of perforated peptic ulcer disease has now been validated, with subsequent eradication of Helicobacter pylori infection. The relationship of H. pylori infection to acutely bleeding ulcers is less clear. Indications for ulcer surgery are predominantly limited now to perforation and bleeding because of the availability of effective acid-reducing medications and recognition of the role of H. pylori infection.
A case of ruptured colon and massive faecal contamination of the peritoneal cavity after a difficult bowel movement is presented. A perforated peptic ulcer was suspected but a rupture of the rectosigmoid colon was found at operation. Surgical management included resection of the affected colon, proximal colostomy and closure of the distal end of the bowel. Definitions of spontaneous rupture and stercoral perforation of the colon are given, and the possible aetiological factors in and management of these rare cases are discussed.
A case of a 67-year-old postmenopausal woman, gravida 2, para 2, with an uterine perforation from actinomycotic infection with Lippes loop IUD is reported. She had the Lippes loop IUD inserted for 35 years, and had never had any pelvic examination nor Papanicolaou smear. She presented with acute abdominal pain. The clinical picture mimicked peptic ulcer perforation. The woman underwent laparotomy and exudative fluid was discovered in the abdominal cavity with the tip of the Lippes loop IUD at one of the two small holes of the uterine fundus. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. The postoperative microscopic pathological report demonstrated characteristics of actinomycosis. She was treated with parenteral high-dose penicillin for 4 weeks followed by oral penicillin for 6 months. The woman had an uneventful recovery. To our knowledge, this is the first case report of uterine perforation due to Lippes loop IUD-associated actinomycotic infection.
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One hundred and seventy cases of perforated duodenal ulcer have been followed up after eight to 10 years. Simple suture of the perforation is recommended. The decision to perform elective surgery is best made during the first two years after perforation rather than at the time of the emergency procedure.
Rheumatic complaints, particularly associated with osteoarthritis, are responsible for about one third of all General Practice consultations in people over the age of 65 and non-steroidal anti-inflammatory drugs (NSAIDs) are used on a vast scale for pain relief. Although the individual risk to life is small NSAIDs are the major cause of serious adverse reactions (ADRs) reported to drug regulatory authorities and ADRs are more common and more serious in the elderly. Gastric ulceration, haemorrhage and perforation are the major concern but fluid retention, renal and hepatic failure, asthma, skin reactions, bone marrow suppression and a host of drug interactions can occur. NSAIDs are responsible for a fifth of all admissions to hospital with bleeding or perforated peptic ulcer and thousands of deaths worldwide. Strategies for minimising the risks of ADRs are discussed and emphasis is placed on using minimal analgesic, rather than anti-inflammatory, doses of short-acting NSAIDs and where possible avoiding their use in high risk patients. For the future cytoprotection with prostaglandin analogues may have a role to play.
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Mortality from peptic ulcer disease in Canada declined significantly for males from 1950-1981, but changed little for females. Gastric and duodenal ulcer mortality, and mortality from perforated and bleeding peptic ulcer showed similar trends. Rates of hospitalization for male duodenal ulcer subjects also declined, with lesser effects among males with gastric ulcer, and females with either gastric or duodenal ulcer. Rates of partial gastrectomy and vagotomy and pyloroplasty or gastrojejunostomy declined from 1968-1981, especially for males. These changes in trends in peptic ulcer disease were contrasted with the overall mortality rate in Canada during the same period, which demonstrated a similar decline for both sexes. The trend to lower mortality, hospitalization and surgical procedures for peptic ulcer disease during this period was associated with a change in cigarette smoking habits in males but not females. The trends identified could not be correlated with the introduction of H2 antagonists for specific therapy of peptic ulcer disease.
The use of endoscopic surgery has increased in gastrointestinal surgery since the introduction of laparoscopic cholecystectomy. It was the aim of this study to investigate the impact of endoscopic procedures in 1998. Laparoscopic cholecystectomy, fundoplication, repair of perforated peptic ulcer, gastric banding procedure, sigmoid resection for diverticulitis, and ileal pouch-anal anastomosis were investigated using techniques of technology assessment. Feasibility, efficacy, and effectiveness were used to evaluate the different types of operation. The statements were graded by three categories of evidence. Laparoscopic cholecystectomy and fundoplication have passed the test. Laparoscopic repair of perforated duodenal ulcer, gastric banding for morbid obesity, and sigmoid resection for diverticulitis are feasible and efficient but not effective today. Laparoscopy-assisted ileal pouch-anal anastomosis has been shown to be feasible but is not yet efficient and effective.
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